Immunization Form

Oregon law requires proof of immunization be provided or a religious or medical exemption be signed prior to a child’s attendance at school, preschool, child care or home day care. This information is being collected on behalf of the Oregon Department of Human Services, Immunization Program and may be released to the Department or the local Public Health Authority by the school or children’s facility upon request of the Department. Vaccine history must include at least the month and year. Please list immunizations in the order they were received.